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#CCT-2320-900425
Supplemental Questionnaire

Last Name
First Name

 

2320 REGISTERED NURSE
SPECIALTY: HOME HEALTH CARE NURSING
SUPPLEMENTAL QUESTIONNAIRE

The purpose of this Supplemental Questionnaire is to determine whether you meet the required licensure and special conditions of a 2320 Registered Nurse in the Home Health Care Nursing specialty as well as to determine your knowledge, skills and abilities in job-related areas that have been identified as critical for satisfactory performance in this position.

The information provided should be consistent with the information on your application and is subject to verification. Verification of experience, licensure, and possession of valid certifications/certificates may be collected at any time during or after the selection process so please choose the best answer for the questions below.


1A.

Do you possess a valid permanent/temporary (including interim permit) California Registered Nurse License issued by the California Board of Registered Nursing?

Yes No
1B.

If you answered "Yes" to Question 1A, please provide your California Registered Nurse license number, your name as it appears on your RN license, and the expiration date of your license. If you answered "No" to Question 1A, please provide additional information below. 

2A.

Which of the special conditions for a 2320 Registered Nurse in the Home Health Care Nursing specialty do you meet in order to qualify for this position?

I have at minimum one (1) year of verifiable experience (equivalent to 2,000 hours) within the last three (3) years as a Registered Nurse in a licensed home health agency.
I have at minimum two (2) years of verifiable experience (equivalent to 4,000 hours) within the last three (3) years as a Registered Nurse in an acute care setting.
I do not possess any of the above.
2B.

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you obtained the experience that meets the special condition that qualifies you for this position.

In addition, please list the name of a supervisor or manager who can verify the information you provided as well as his or her contact information. If you do not have experience in these areas, type N/A.

Note: If you do NOT possess a minimum of one (1) year of verifiable experience (equivalent to 2,000 hours) within the last three (3) years as a Registered Nurse in a licensed home health agency OR a minimum of two (2) years of verifiable experience (equivalent to 4,000 hours) within the last three (3) years as a Registered Nurse in an acute care setting, please still provide the information requested as well as the Registered Nurse experience you do possess.

2C.

Please provide a brief description of your work experience that meets the special condition that qualifies you for this position. Include in your answer your specific role and primary duties and responsibilities (e.g., charge nurse). If you do not have experience in these areas, type N/A.

3A.

Please select the highest level of education you have completed.

Associate degree in Nursing (ASN/ADN)
Bachelor of Science degree in Nursing (BSN)
Master of Science degree in Nursing (MSN)
None of the above
3B.

Please list the school(s) where you obtained your degree(s). If you do not possess any of the degrees above, type N/A.

4A.

Please select the valid certification(s)/certificate(s) you possess. You may select more than one.

Certification for Adult, Pediatric and Neonatal Critical Care Nurses (CCRN)
Certified medical-surgical (CMSRN)
Home Health Case Manager certificate
Home Health Nurse certificate
Registered Nurse-Board Certified (RN-BC)
None of the above
4B.

Please list the name of the agency(s) that issued the certification(s)/certificate(s) you possess. If applicable, include the expiration date.

If you do not possess any of the certifications/certificates listed above, type N/A.

5A.

Please indicate the total amount of experience you have working as a Registered Nurse in a licensed home health agency.

No experience
I have worked 12 months or less as a Registered Nurse in a licensed home health agency.
I have a total of 13 to 24 months of experience working as a Registered Nurse in a licensed home health agency.
I have a total of 25 to 36 months of experience working as a Registered Nurse in a licensed home health agency.
I have more than 36 months of experience working as a Registered Nurse in a licensed home health agency.
5B.

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you obtained your experience as a Registered Nurse in a licensed home health agency.

In addition, please list the name of a supervisor or manager who can verify the information you provided as well as his or her contact information. If you do not have experience in this area, type N/A.

5C.

Please provide a brief description of your work experience as a Registered Nurse in a licensed home health agency. Include in your answer your specific role and primary duties and responsibilities (e.g., charge nurse). If you do not have experience in this area, type N/A.

6A.

Please indicate the total amount of experience you have working as a Registered Nurse in an acute care setting.

No experience
I have worked 24 months or less as a Registered Nurse in an acute care setting.
I have a total of 25 to 36 months of experience working as a Registered Nurse in an acute care setting.
I have a total of 37 to 48 months of experience working as a Registered Nurse in an acute care setting.
I have more than 48 months of experience working as a Registered Nurse in an acute care setting.
6B.

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you obtained your experience as a Registered Nurse in an acute care setting.

In addition, please list the name of a supervisor or manager who can verify the information you provided as well as his or her contact information. If you do not have experience in this area, type N/A.

6C.

Please provide a brief description of your work experience as a Registered Nurse working in an acute care setting. Include in your answer your specific role and primary duties and responsibilities (e.g., charge nurse). If you do not have experience in this area, type N/A.

7A.

Please indicate the total amount of experience you have as a Registered Nurse using the Outcome and Assessment Information Set (OASIS).

No Experience
I have 12 months or less of experience as a Registered Nurse using the Outcome and Assessment Information Set (OASIS).
I have more than 12 months of experience as a Registered Nurse using the Outcome and Assessment Information Set (OASIS).
7B.

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you obtained your experience as a Registered Nurse using the Outcome and Assessment Information Set (OASIS).

In addition, please list the name of a supervisor or manager who can verify the information you provided as well as his or her contact information. If you do not have experience in this area, type N/A.

7C.

Please provide a brief description of your work experience as a Registered Nurse using the Outcome and Assessment Information Set (OASIS). Include in your answer your specific role and primary duties and responsibilities (e.g., charge nurse). If you do not have experience in this area, type N/A.

8A.

Please indicate the total amount of experience you have as a Registered Nurse working with an underserved, diverse urban population.

No experience
I have 12 months or less of experience as a Registered Nurse working with an underserved, diverse urban population.
I have more than 12 months of experience as a Registered Nurse working with an underserved, diverse urban population.
8B.

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you obtained your experience as a Registered Nurse working with an underserved, diverse urban population

In addition, please list the name of a supervisor or manager who can verify the information you provided as well as his or her contact information. If you do not have experience in this area, type N/A.

8C.

Please provide a brief description of your work experience as a Registered Nurse working with an underserved, diverse urban population. Include in your answer your specific role and primary duties and responsibilities (e.g., charge nurse) and the specific location of the underserved, diverse urban population. If you do not have experience in this area, type N/A.

9A.

Do you have experience using point of care documentation software such as Encore in your duties as a Registered Nurse?

Yes No
9B.

If you have experience using point of care documentation software in your duties as a Registered Nurse, where did you obtain this experience? Select all that apply.

Alameda County Medical Center - Highland Hospital
Alta Bates Summit Medical Center
California Pacific Medical Center
Kaiser Permanente
Laguna Honda Hospital and Rehabilitation Center
Marin General Hospital
Mills-Peninsula Medical Center
Saint Francis Memorial Hospital
Other
I do not have experience using point of care documentation software.
9C.

If you selected "Other", please specify in the space below. Otherwise, type N/A.

9D.

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you obtained your experience using point of care documentation software.

In addition, please list the name of a supervisor or manager who can verify the information you provided as well as his or her contact information. If you do not have experience in this area, type N/A.

9E.

Please provide a brief description of your work experience as a Registered Nurse using point of care documentation software. Include in your answer the name of the point of care documentation software you used. Also include your specific role and primary duties and responsibilities (e.g., charge nurse). If you do not have experience in this area, type N/A.

10A.

Can you speak any of the following languages? You may select more than one.

Arabic
American Sign Language
Burmese
Cambodian
Chinese (Cantonese)
Chinese (Other)
Chinese (Mandarin)
Japanese
Korean
Laotian
Russian
Spanish
Tagalog (Philippines)
Vietnamese
Other
None of the above
10B.

If you selected "Other", please specify in the space below. Otherwise, type N/A.

11A.

Can you read any of the following languages? You may select more than one.

Arabic
American Sign Language
Burmese
Cambodian
Chinese (Cantonese)
Chinese (Other)
Chinese (Mandarin)
Japanese
Korean
Laotian
Russian
Spanish
Tagalog (Philippines)
Vietnamese
Other
None of the above
11B.

If you selected "Other", please specify in the space below. Otherwise, type N/A.

12A.

Can you write in any of the following languages? You may select more than one.

Arabic
American Sign Language
Burmese
Cambodian
Chinese (Cantonese)
Chinese (Other)
Chinese (Mandarin)
Japanese
Korean
Laotian
Russian
Spanish
Tagalog (Philippines)
Vietnamese
Other
None of the above
12B.

If you selected "Other", please specify in the space below. Otherwise, type N/A.

 

I certify that I am the author of this form and that all the information presented is true and based upon my experience. I understand that prior to an appointment I may be required to provide written verification of any of the information provided above and that I may be required by the hiring department to participate in performance test(s) during the probationary period. I further understand that any false, incomplete, or incorrect statement may result in disqualification, dismissal or termination of employment with the City and County of San Francisco.